Primary Dysmenorrhea - UP 2018 PPs/gynaecolo… · Acupuncture and acupressure Further well...
Transcript of Primary Dysmenorrhea - UP 2018 PPs/gynaecolo… · Acupuncture and acupressure Further well...
Primary DysmenorrheaEvidence based management
guidelines
Prof Leon C Snyman
B Med Sci, MBChB, M Prax Med, M Med(O&G), FCOG(SA), PhD
Gynaecologic Oncology Unit
Kalafong Provincial Tertiary Hospital
University of Pretoria
What is it
Recurrent lower abdominal cramping
during cycle
Classification
Primary dysmenorrhoea
Secondary dysmenorrhoea
Endometriosis
Adenomyosis
Leiomyomas
Why is it important
It causes
Pain in young women
Absenteeism
High prevalence
Epidemiology
PD
25% of all women
90% of adolescents
Absenteeism
Up to three days
per cycle in 15%
Epidemiology
More in:
In smokers
Early age menarche
Longer cycles
Pathophysiology
True aetiology uncertain
Most plausible
endometrial prostaglandin production →
myometrial contractions & vasoconstriction → uterine
ischemia → pain
8 to 72 hours
Diagnosis
History
Clinical findings
Differential diagnosis
Special investigations
Differential diagnosis
Causes of pelvic pain
Investigate appropriately according to
findings obtained in history
Pain syndrome
PD not regarded as chronic pain syndrome
Many shared features
QOL
hypothalamic-pituitary axis
Alterations central processing noxious stimuli
Management
PD
Symptom relief
Grading of disease
Counselling
Appropriate follow-up and support
Management
SD
Treat underlying cause
Quality of evidence
Most
Moderate, low, or very low grade
Level of evidence (LOE) DescriptionLevel I Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or
evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results.
Level IIEvidence obtained from at least one well-designed RCT (e.g. large multi-site RCT).
Level IIIEvidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental).
Level IVEvidence from well-designed case-control or cohort studies.
Level VEvidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).
Level VIEvidence from a single descriptive or qualitative study.
Level VIIEvidence from the opinion of authorities and/or reports of expert committees.
NSAIDs
vs placebo
73 RCTs
OR 4.5, 95% CI 3.85 to 5.27 pain relief
NSAIDs
vs paracetamol
OR 1.90, 95% CI 1.05 to 3.44 pain relief
NSAIDs
vs Aspirin
1 RCT 34 women
NSAIDs better RR 2.29 95% CI 1.09 to 4.79
pain relief
NSAIDs
vs NSAIDs
Insufficient evidence
NSAIDs
Effective:
Pain relief
Restriction of daily activities
(RR 0.65 95% CI 0.51 to 0.83)
Absence from school
(RR 0.46 95% CI 0.34 to 0.61)
NSAIDs
Beware: significant risk of adverse effects
vs placebo:
GIT ulceration, bleeding (traditional NSAIDs)
CVS risk (some COX-2)
Aspirin
vs placebo
Systematic review 8 RCTs
RR 1.60 95% CI 1.12 to 2.29 pain relief
2 other systematic reviews 4 RCTs → NS
Aspirin
Daily activities and absenteeism
Data: NS
Aspirin
Adverse effects
Compared with placebo: NS
Paracetamol
vs placebo
Very low quality evidence: NS
COC
Frequently used
Limited evidence
497 women in review 6 RCTs
Daily activities
No data
COC
vs placebo
Effective
OR 2.01 95% CI 1.32 to 3.08
Adverse effects: NS
COC
vs NSAIDs
No data
Herbal and dietary therapies
Magnesium
Vitamin B12
Might be beneficial
Evidence weak
Small numbers
Dosage: unknown
Herbal and dietary therapies
Other herbal and dietary therapies
Insufficient data
Behavioural interventions
Might be beneficial for pain relief
Pain management training
Relaxation
Interpret with caution; poor quality data
Exercise
Might be beneficial pain relief
Interpret with caution: 1 single RCT
Transcutaneous electrical nerve stimulation
7 RCTs
High frequency TENS
More effective than placebo pain relief
OR 7.2 95% CI 3.1 to 16.5
Transcutaneous electrical nerve stimulation
TENS
Absenteeism
Data: NS
TENS
Low frequency
Data pain relief: NS
TENS
vs NSAIDs
low quality evidence (32 women) favours
NSAID
OR 0.26 95% CI 0.09 to 0.75
Chinese Herbal Medicine
vs placebo
Results unclear
Data could not be combined
Topical Heat
Abdominal heated patch (38.9C)
vs unheated
Effective for pain relief
Topical Heat
vs NSAIDs
Low quality evidence: NS
Topical Heat
vs paracetamol
Topical heat more effective
Mean pain score 2.48 compared to 2.17 (p =
0.015)
Acupuncture
Pain relief:
Better than placebo, NSAIDs &
Chinese herbs
Acupressure
Better than placebo for pain relief and
menstrual symptoms
Acupuncture and acupressure
Further well designed RCTs needed
Interventions not effective
β2 – agonists
Spinal manipulation by physiotherapists and
chiropractors
Surgical intervention of nerve pathways
Now
So what?
Implication for practice
What are we trying to achieve
Pain relief
Less absenteeism
Exclude pathology
Treatment options
Some options
achieve both
achieve one
are counterproductive
are not practically feasible
Most practical
COC
Additional advantages
NSAIDs prn
Maybe heat patch
COC
Without placebo
Women were not designed to menstruate
Women were not designed to menstruate
Placebo: since 1950
The opportunity
Adolescents seldom get sick
Opportunity
Counsel regarding safe sex
and contraception, HPV vaccine
Etc
Conclusion
Common condition
Many women do not seek help → normal plight of
being female
When obtaining history: ask about PD
Conclusion
When treating PD
Use the opportunities it created
Contraception in
perimenopausal women
Prof Leon C Snyman
B Med Sci, MBChB, M Prax Med, M Med(O&G), FCOG(SA), PhD
Gynaecologic Oncology Unit
Kalafong Provincial Tertiary Hospital
University of Pretoria
Introduction
Population with specific needs and challenges
Which methods are safe
When and how to stop
Fertility
Women >40 years → natural ability to fall pregnant
Conception rate 12/1000 compared to 110/1000 in women 20 -
25 years
Still require effective and safe contraception
Perimenopausal women
Generally: in frequency of intercourse
Some are in new relationships often resulting in in
coital frequency
Older women may abandon contraception
When unintended pregnancy → 35% will have TOP
Contraceptive methods
No method is contra-indicated on age alone
Less effective methods can be used effectively at this
age in combination with a natural decline in ability to fall
pregnant
Risk of contraception to be weighed against risk of
unintended pregnancy
Combined oral contraceptives (COCs)
Can safely be used up to menopause in:
Non-smokers
No risk factors for cardiovascular disease
No risk factors for arterial or venous disease
Not: Obesity, smoking, hypertension, DM, migraine
Some Risks of COCs
VTE
Absolute risk remains small
18 events per 100 000 users 40 – 44 year old – 2 x of 20 -24
years
Risk highest in first year and may decrease with prolonged use
Some Risks of COCs
Breast cancer
Risk very small and is age related
RR 1.24 and normalises after 10 years of stopping
Cervical cancer
Risk with duration of use
RR 4.03 after 10 years → screen!
Benefits
Reduced risk of
Ovarian cancer – RR 0.42 after 15 years use & protection lasts
for 30 years
Endometrial Ca – 40% risk lasting 15 years
Beneficial effect on BMD
Cycle and perimenopausal symptom control
COCs
Any monophasic 30 µg EE
21/7, 24/4, continuous regimen or tailored extended
use
Progestogen only methods
Reliable but not very popular
Can cause irregular and unpredictable bleeding
Breast cancer risk than COCs
Long term DMPA → reversible BMD
Levonorgestrel releasing intrauterine system (LNG-
IUS)(Mirena)
Very effective and safe
Licensed for 5 years, very safe for 7 years in
women >37 years
Effective in treating HMB
Endometrial protection when HT required
Copper IUD
Optimal for older women with normal cycles
Safe and effective
Irregular HMB needs to be investigated
Barrier methods and spermicides
Condoms more effective in this age group compared to
younger women
Can be problematic in males experiencing erectile
dysfunction when using condoms
Male and female condoms same efficacy
Spermicides should not be used alone
Other methods
Fertility awareness based methods → less reliable
Coitus interruptus not recommended
Emergency contraception is safe
Levonorgestrel-only emergency pills should be used
Single dose 1.5 mg up to 5 days after event
IUD
Permanent measures
Often used in women > 40 yrs
Very effective
Laparoscopic procedure Filschie clip consider
salpingectomy → reduces ovarian cancer risk
Hysteroscopic tubal occlusion – no more
Vasectomy
Natural FP
For those who cannot use available options
For those who chose to use it
NFP
Limited knowledge
Women seldom counselled about this
Physiology
Six fertility days per cycle
Sperm survives 5 days in female genital tract
Oocyte life span about 24 hours
Best chance – intercourse before ovulation
Physiology
Ovulation occurs in mid-cycle in 30% of cycles and
within 4 days before or after the midpoint in 95% of
cycles
Physiology
Cervical secretions
Initially absent in the first 3 to 4 days of cycle
Before and immediately after ovulation secretions more in
volume and clear in appearance
Disappear until after the next menstruation
Physiology
The probability of conception is very low (near zero)
when intercourse occurs on days with no secretion
and is about 30% when intercourse occurs on days
with the most fertile type mucus
Concept
Identification of fertile days
Cycle length
Clinical indicators of ovulation:
cervical secretions
basal body temperature
Concept
Avoid intercourse or use barrier on fertile days
Classification
Fertility awareness based methods
Standard Days Method
TwoDay method
Ovulation method
Symptothermal method
Other
Standard Days Method
For women with cycles between 26 and 32 days
Unprotected intercourse should be avoided from
day 8 to day 19
Pregnancy rate: <5 per 100 women years over 13
cycles with correct use and 12 with typical use
Cycle Beads
Two Day Method
Unprotected intercourse is avoided on any day with
vaginal secretion as well as the following day
Two Day Method
The mean length of the fertile period according to
this method, where the presence of secretions is
important and the characteristics are ignored, is 13
days
Two Day Method
Correct use pregnancy rate studied over 13 cycles
is 3 pregnancies per 100 women years and <14 for
typical use
Symptothermal Method
Vaginal secretions is combined with measurements of basal
body temperature
Onset of secretions indicate the beginning of the fertile
period
Rise in basal body temperature signals the end
Symptothermal Method
Temperature readings and information on
secretions are recorded on a chart
Unprotected intercourse avoided
on days with secretions
days after intercourse on pre-ovulatory days as semen can be
confused with secretions
Symptothermal Method
Unprotected intercourse avoided
until there is a rise in basal body temperature for three consecutive
days after 6 days of lower temperature, or 4 days after the last wet
secretions
Symptothermal Method
Correct use has a pregnancy rate of 2 per 100
women years and typical use between 13 and 20
When to stop contracetion
Women up to 50:
2 years after last spontaneous menstrual period
Women > 50:
1 year after last spontaneous menstrual period
When to stop
In COC users
Age 50 → switch to POP or non-hormonal → continue until 1
year after last spontaneous menstrual period, or 2
measurements of FSH 30 IU/l 6 to 8 weeks apart
When to stop
POP users
FSH levels → if elevated twice → discontinue after using for
another year
Or
Continue use until 55 years of age and then stop
When to stop
DMPA
Use after 45 yrs → counsel about risk of BMD → allow to
continue until age 50 yrs if no osteoporosis risk factors
Women with osteoporosis risk factors after age 40 yrs should
consider alternative methods
When to stop
LNG-IUS and amenorrhoea
FSH levels → if elevated twice → discontinue after using for
another year
Or
Continue use until 55 years of age and then stop
Endometrial protection in HT users
Conclusion
Peri-menopausal women require contraception
All options are available
Counsel and individualise
Menopausal Hormone
Therapy and Breast Cancer
Risk
Prof Leon C Snyman
B Med Sci, MBChB, M Prax Med, M Med(O&G), FCOG(SA), PhD
Gynaecologic Oncology Unit
Kalafong Provincial Tertiary Hospital
University of Pretoria
Outline
1. Menopausal hormone therapy
Consensus statement
2. MHT and breast cancer risk
3. Communicating risk
Menopausal hormone therapy
Who needs hormone therapy?
Symptomatic peri- and post-menopausal women in
whom treatment is not contra-indicated
What are the concerns
Concerns patients have
Concerns doctors have
What are the concerns patients
have?
Weight gain
Cancer risk and all the bad things they hear or read in
the lay press
HT and weight gain
What is the evidence?
Weight gain: kg (E)
Cochrane database of Systematic Reviews 1999 Issue 3
Weight gain: kg (E+P)
Cochrane database of Systematic Reviews 1999 Issue 3
Weight gain: BMI (E)
Weight gain: BMI (E+P)
Cochrane database of Systematic Reviews 1999 Issue 3
HRT and weight gain
The evidence show no increase in
weight gain
HT and weight gain
Hormone preparations have zero kilojoules
WHI trial
WHI 2002
Labelled HRT as dangerous based
on increaed breast cancer risk
This was reported as a 26% increase in
breast cancer risk
WHI 2002
Labelled HRT as dangerous based
on increaed breast cancer risk
An absolute inreased risk of 8 additional
invasive breast cancers per 10 000 users of
E+P per year
Prospective study to evaluate the
effectiveness of HRT in preventing
CHD in asymptomatic post-
menopausal women
WHI study
Prospective study to evaluate the
effectiveness of HRT in preventing CHD
in asymptomatic post-menopausal
women
Mean age of population studied 63
Hypertension and obesity in significant numbers
WHI study
Don’t prescribe HRT to asymptomatic
63 year old (obese and hypertensive)
solely to prevent CHD, because it
does not prevent CHD in this
population
WHI study
The concerns doctors have
regarding HRT risk
VTE /CVI
Cardiovascular disease
Breast cancer
Global consensus statement 1
Menopausal Hormone Therapy (MHT) including
tibolone is the most effective treatment for
vasomotor symptoms
< 60 years of age or within 10 years after onset of menopause
How effective are hormones in
treating menopausal symptoms
Oestrogen is highly effective
Nothing else comes close to it
Hot flushes: frequency/week
Cochrane database of Systematic Reviews 2009 Issue 1
Hot flushes: severity
Cochrane database of Systematic Reviews 2009 Issue 1
Hot flushes: severity (odds ratio)
Cochrane database of Systematic Reviews 2009 Issue 1
Global consensus statement 2
MHT including tibolone is effective and
appropriate for the prevention
bone loss
osteoporosis-related fractures in at-risk women before age
60 years or within 10 years after menopause
Global consensus statement 3
RCTs and observational data provide evidence that
standard-dose oestrogen-alone MHT may decrease
CHD and all-cause mortality in women < 60 years of
age and within 10 years of menopause
Global consensus statement 3
Data on oestrogen plus progestogen MHT in this
population show a similar trend for mortality but in
most RCTs no significant increase or decrease in
coronary heart disease has been found
Global consensus statement 4
Local low-dose oestrogen therapy is preferred
for women whose symptoms are limited to
vaginal dryness or associated discomfort with
intercourse
Global consensus statement 4
MHT including tibolone is effective in the
treatment of vulvovaginal atrophy -
component of the genitourinary syndrome of
menopause (GSM)
Global consensus statement 5
Oestrogen as a single systemic agent is appropriate
in women after hysterectomy but additional
progestogen is required in the presence of a uterus
(probably also for women who had endometriosis)
Global consensus statement 6
The option of MHT is an individual decision in terms of
quality of life and health priorities as well as personal
risk factors such as age, time since menopause and
the risk of venous thromboembolism, stroke, ischemic
heart disease and breast cancer
Global consensus statement 7
The risk of VTE and ischemic stroke increases
with oral MHT but the absolute risk is rare below
age 60 years
Observational studies point to a lower risk with
transdermal therapy
VTE and hormone therapy
Transdermal oestrogen not associated with
increased risk (observational data)
Absolute risk remains small
Don’t stop and start
Stroke risk and hormone therapy
Increased risk regardless of age and years since onset
of menopause
Absolute excess risk of stroke in women 50-59 years
minimal
2 additional cases per 10 000 person years
8 additional cases per 10 000 person years in WHI
Global consensus statement 8
The risk of breast cancer in women over 50 years
associated with MHT is a complex issue
Decreased risk for E alone
Possible increased risk with E + P
Global consensus statement 8
The risk of breast cancer attributable to MHT is rare
Incidence of <1.0 per 1000 women per year of use
Similar or lower than the increased risk associated with common factors
such as sedentary lifestyle, obesity and alcohol consumption
The risk may decrease after treatment is stopped, but data are
inconsistent
Global consensus statement 9
The dose and duration of MHT should be consistent
with treatment goals and safety issues and should be
individualised
Global consensus statement 10
The use of custom-compounded bio-identical
hormone therapy is not recommended
Global consensus statement 11
Current safety data do not support the
use of MHT in breast cancer survivors
MHT and Breast Cancer Risk
Breast cancer risk
Varies substantially between women
Those with low baseline risk will experience less
excess risk
Reproductive breast cancer risk factors
Breast cancer risk and ageProbability
Birth to age 49 1.9 1 in 53
Age 50 – 69 2.3 1 in 44
Age 60 – 69 3.5 1 in 29
Age 70 and older 6.7 1 in 15
Lifetime risk 12.3 1 in 8
Breast cancer riskFactor RR 95% CI
>10 kg weight gain since menopause 1.18 1.03 – 1.35
Female air hostess night shift 1.51 1.36 – 1.68
Female night shift worker 1.44 1.26 – 1.65
Physical activity 0.88 0.85 – 0.90
Perspective
None of these consistently shown to be risk factors
Post-hoc statistical manipulation such as data
mining or retrospective sub-stratification to find
publishable “statistical” result
WHI follow-up data
WHI secondary analysis 2007
Women who began HRT within the first 10 years following
the menopause actually reduced their risk of coronary
heart disease (HR of 0.76)
WHI secondary analysis 2007
The data also showed that hormone users aged 50 – 59
had a 30% lower risk of all cause mortality than those in
placebo group
WHI longer follow-up
11-year follow-up study
Women randomised to CEE/MPA without prior exposure to
HRT had no increase in breast cancer incidence relative to
women randomised to placebo (HR 1.16; 95% CI 0.98 – 1.37)
WHI longer follow-up
CEE alone
Reduced breast cancer incidence (HR 0.82; 95% CI 0.65 – 1.04) (NS)
In adherent women
Statistically significant reduction in breast cancer incidence (HR 0.67; 95% CI 0.47
– 0.97)
WHI longer follow-up
After 12.6 years
Significant persistence in the reduction in breast cancer
incidence in the group of women randomised to CEE
regardless of adherence
(HR 0.77; 95% CI 0.62 – 0.95)
From WHI
Data from the WHI clearly show
over 11 years, there is no increased risk of breast cancer in
HRT-naïve women who received CEE/MPA
From WHI
Data from the WHI clearly show
over 11 years, there is no increased risk of breast cancer in
HRT-naïve women who received CEE/MPA
a decreased risk of breast cancer in those women who
received CEE alone
From WHI
Furthermore, for all women in the WHI CEE/MPA trial, there was
no increased risk for breast cancer in the first 5 years
HRT and breast cancer risk
It remains unproven as to whether
or not HRT increases the risk of breast cancer
Even if it does the magnitude of that risk is very small and
less than many common lifestyle factors
WHI in context
Therapy Event RR
(95% CI
Additional cases
per 10 000/year
CEE/MPA Breast cancer death 1.96 (1.00 – 4.04) 1.30
Raloxifene Fatal stroke 1.49 (1.00 – 2.24) 20
Aspirin Sudden death 1.96 (0.91 – 4.23) 5
Fenobarb Total mortality 1.11 (0.95 – 1.29) 13
ß-carotene Total mortality 1.17 (1.03 – 1.33) 25
Ca supplement Total mortality 1.09 (0.96 -1.23) 8
HRT and breast cancer mortality
Most randomised controlled trials and observational study
data indicate that HRT is associated with either a null or
reduced overall breast cancer mortality
HRT and breast cancer mortality
HRT as a risk factor for death from breast
cancer
Women using MHT at the time of diagnosis of
breast cancer have improved survival rates
Paradox: possible slightly increased risk and
better outcome
earlier diagnosis, localised, smaller, better differentiated
Survival in breast cancer: users vs non
users
In a nutshell
HRT does not cause breast cancer
E & P might have a zero to small risk
E reduces risk
Better survival in HRT users
Causing disease
RR of lung cancer in male smoker vs non
smoker is 26.07
RR of cervical cancer if HPV 16 positive vs
HPV 16 negative is
HR breast cancer WHI 2002 was
(95% CI 1.00 – 1.59)
435
1.26
In perspective
RR
HR breast cancer WHI 2002 was 1.26 (95%
CI 1.00 – 1.59)
AR
4 per 1000 women taking E+P for 5 years
Millions of women stopped their
HRT following this non-significant statistic
How do you communicate risk?
P value?
Comparative data?
Compared to average of population?
Compared to other conditions?
How do you frame it?
Positively?
Negatively?
How do you communicate risk?
What terminology do you use or should you
use?
Relative risk? Relative risk reduction?
Odds Ratio? Hazard ratio?
Absolute risk? Absolute risk reduction?
Numbers needed to treat? Numbers needed to harm?
Common? Rare? Very rare?
The problem
Doctors struggle to understand risk
Patients don’t understand it
For the most part, there is confusion and continious
debate between clinicians about how best to translate
concepts of epidemiological risk into clinical risk
How should you communicate risk?
The language statisticians use…
The incidence in exposed individuals divided by the incidence in
unexposed individuals
Relative Risk
The odds that an individual with a specific condition has been
exposed to a risk factor divided by the odds that a control has been
exposed
The odds ratio is used in case-control studies
The odds ratio provides a reasonable estimate of the relative risk for
uncommon conditions
Odds Ratio
Ratio of instantaneous risk in two experimental arms
It represents point estimate at any given point of time, it is not
cumulative estimate like relative risk and odds ratio
Interpretation remains same as Odds ratio, keeping in mind the
time factor
Hazard Ratio
The RR and OR are interpreted relative to the number one
An OR of 0.6, for example, suggests that patients exposed to a variable
of interest were 40% less likely to develop a specific outcome
compared to the control group
An OR of 1.5 suggests that the risk was increased by 50%
Risk reduction can be presented using:
relative risk reduction (RRR)
absolute risk reduction (ARR), or
numbers needed to treat (NNT)
Relative, absolute and excess
risk
Risk of dying in a plane crash = 1 in 10
million
With five plane flights: risk = 5 in 10
million
The RR = 5.0 (500% increase)
Absolute excess for five fligts is 4 in 10 million
The RRR is the reduction of risk in the intervention group
relative to the risk in the control group
For a risk of 20% in the control group and a risk of 10% in
the intervention group, the RRR would be 50%
The ARR is the difference in risks between two groups
For a risk of 20% in the control group and a risk of 10% in
the intervention group the ARR would be 10%
In a clinical trial of a drug to prevent migraines, 2 of 100 people taking
the drug experience a migraine (2%), compared with 4 of 100 people
taking a placebo (4%)
The absolute risk reduction is 2%, because 4% − 2% = 2%
That is, there were 2% fewer migraines in people taking the drug
In a clinical trial of a drug to prevent migraines, 2 of 100 people taking
the drug experience a migraine (2%), compared with 4 of 100 people
taking a placebo (4%)
The relative risk reduction is 50%, because 4% of people taking
placebo had a migraine, but only 2% of those taking the drug
The NNT is the number of patients who need to be
treated (or screened) to prevent one additional adverse
outcome
For a risk of 20% in the control group and a risk of 10%
in the intervention group NNT = 10
Ms Jones
Just turned 50, fit and healthy
Fam hist = neg; Men at 14; 1st child at 26
Wants mammography screening
Her sister thinks it can only be a good thing; Ms Jones is sceptical
– concerned about false alarms
She wants to know about benefits and harms
Mammography data
USPSTF review → 15% decrease RR in mortality
Meta analysis including the Age trial → 16% RR
reduction in mortality
Ms Jones could be presented with the following statements:
RRR:
Early detection with mammography reduces the risk of dying from breast cancer
by 15%
ARR:
Early detection with mammography reduces the risk of dying from breast cancer
by 0.05%
NNT:
2000 women need to have regular mammograms for more than 10 years to
prolong one life
Some risk communication suggestions
A recent review of evidence suggested that using RRR makes
treatment benefits and changes in risk seem larger than they
are
Information on risk reduction be consistently presented using
ARR
A Cochrane review of 22 randomised controlled trials suggests that,
compared with general risk information, personalised risk
communication (whether written, spoken, or visually presented)
in the context of screening tests can lead to more accurate risk
perception, improved knowledge, and increased uptake of screening
tests
The risk of breast cancer can be presented as a general
population based risk estimate (generalised risk information)
or on the basis of the individual’s own risk factors
(personalised risk information)
There is growing evidence to support the use of pictographs to present
natural frequencies, with evidence suggesting that these are well
understood and that they effectively support communication about
individual statistics
Haroon Ahmed et al. BMJ 2012;344:bmj.e3996
©2012 by British Medical Journal Publishing Group
How to communicate risk?
Use absolute risk
Be careful with comparative risks
Provide risk as well as benefit
“Transaction” where patients “buy” benefits
with a “currency” called risk
More than one paradox in MHT
Paradox 1
Women produce hormones for the best part of 40
years, no problem
When they stop producing their own, it all of a
sudden becomes “dangerous” to prescribe hormones
Paradox 2
Having to convince women that an intervention
associated with a 30 to 40% reduction in all cause
mortality, is safe and will not kill them
Thank you